Provider Demographics
NPI:1124061585
Name:REYNOLDS, JOSEPH C II (PA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:REYNOLDS
Suffix:II
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820 HICKORY FLAT HWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2099
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:750 TOWNPARK LN NW
Practice Address - Street 2:KAISER PERMANENTE TOWNPARK COMPREHENSIVE MEDICAL CENTER
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5579
Practice Address - Country:US
Practice Address - Phone:770-514-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007884-1363A00000X
GA47000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F2431Medicare ID - Type Unspecified
P58601Medicare UPIN